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Application For Certificate Of Consent To Administer Workers Comp Self Insurance Claims A 4-50 - California
| Application For Certificate Of Consent To Administer Workers Comp Self Insurance Claims Form. This is a California form and can be used in General Workers Comp . |
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State of California Department of Industrial Relations Self Insurance Plans 2265 Watt Avenue, Suite 1 Sacramento, CA 95825 Phone (916) 483-3392 FAX (916) 483-1535 Page 1 Our File: APPLICATION FOR A CERTIFICATE OF CONSENT TO ADMINISTER WORKERS' COMPENSATION SELF INSURANCE CLAIMS INSTRUCTIONS: All questions below must be answered. If not applicable, enter "N/A". The undersigned administrative agency hereby applies for a Certificate of Consent to Administer workers' compensation claims for permissibly self-insured employers in accordance with the provisions of California Labor Code Section 3702.1. 1. Date: 2. Type of Application: New Addition of Reporting Location(s) Only Renewal of Existing Certificate to Administer No.: 3. Name of Administrative Agency: 3. Street Address: 3. Mail Address: 3. City: State: Zip: 4. Type of Entity: Corporation Partnership Proprietorship Yes Yes JPA No No 5. Is the applicant a workers' compensation insurance carrier? 5. If yes, is the applicant a separate subsidiary to administer claims? 6. Name of Owner(s): 7. List the manager's name and adjusting location addresses and phone numbers below: 1. Name of Manager: 1. Administrative Agency: 1. Street Address: 1. City: 1. Phone: ( ) State: FAX: ( ) Zip: 1. Two-digit SIP Adjusting Location Number Assigned to This Office: Form A4-50 (Rev 8/96) 2001 © American LegalNet, Inc. Page 2 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 2. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 3. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 4. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 5. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 2001 © American LegalNet, Inc. Page 3 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 6. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 7. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 8. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 9. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip: 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 2001 © American LegalNet, Inc. Page 4 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 10. Name of Manager: 10. Administrative Agency: 10. Street Address: 10. City: 10. Phone: ( ) State: FAX: ( ) Zip: 10. Two-digit SIP Adjusting Location Number Assigned to This Office: 8. List below the name of the city of each adjusting location in number 7 above; then the name of each self-insured8. 8. employer serviced at that adjusting location; the number of the Certificate to Self Insure for each self-insured 8. employer; and the name of the claims adjuster--who has demonstrated their individual competence by passing the 8. Self Insurance Administrator's examination--who is responsible for the self insurer's claims at that adjusting location: Adjusting Location (City) Name of Self-insured Employer Certificate Number Name of Competent Person 2001 © American LegalNet, Inc. Page 5 8. (Continued) Adjusting Location (City) Name of Self-insured Employer Certificate Number Name of Competent Person 2001 © American LegalNet, Inc. Page 6 9. Period of Time for Certificate Issuance Requested: 1 Year 2 Years 3 Years 10. Fees Due with this Application (not applicable to joint powers authorities and insurance carriers): 10. (a) Base Fee $650 for each Administrative Agency per year (includes initial adjusting location): $650 x years = $ 10. (b) Adjusting Location Fee of $100 for second and subsequent adjusting locations per year: $100 x additional locations x years = $ 10. (c) Fees Submitted with Application: $ The information submitted in this application is true and correct to the best of my knowledge. Signature of Person Completing Application: Typed Name of Person Completing Application: Title of Person Completing Application: Phone number: ( Date: ) 2001 © American LegalNet, Inc.
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